Iowa's STI Program uses this two-page form for clinics to report a diagnosis of chlamydia, gonorrhea or syphilis together with the treatment given. A clinician meets it when an STI test result comes back positive. Page 1 is the report, including expedited partner therapy and HIV and syphilis testing at the visit; page 2 gives Iowa's treatment recommendations and tips for filling it out.
The clinician or clinic staff who diagnose and treat the infection complete the whole form, which is marked for completion by the clinic. A patient label may be used for demographics, with any missing items filled in by hand.
Download the current version from the source each time; forms change without notice.
Iowa Confidential Report of Sexually Transmitted Infection—Chlamydia, Gonorrhea & Syphilis
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The form says to report within 3 days of receiving the test result, by fax to the Iowa STI Program. Include the treatment date, which is a required field for each diagnosis, and quantitative titers for any positive VDRL or RPR.
No. The form states that it is not for reporting HIV or AIDS. Iowa HHS asks providers to report HIV and AIDS by phone to its HIV program, using the numbers printed at the top of the form, and to use this form only for chlamydia, gonorrhea and syphilis.
Yes. Page 1 asks whether expedited partner therapy was offered or provided. Page 2 notes that EPT should be offered to treat partners of people diagnosed with chlamydia or gonorrhea who are unlikely to seek clinical care, and that it is legal under Iowa Code 139A.41.